28 Jun 2021 Nicholas Jonathan SPOONER · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 1 Denial of mental health support for people in crisis with co-occurring substance abuse View source
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Nicholas Jonathan SPOONER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Nicholas Spooner had a long-standing dual diagnosis of mental ill health and polysubstance abuse and was moved to Brighton for his own safety. He fell from the window of his third-floor room after removing the window restrictors, sustaining multiple potentially survivable injuries, and later died directly as a result of COVID-19 pneumonitis. The principal concern was the need for specialist dual-diagnosis services, including outreach, drop-in and day-centre support for people experiencing mental health crises entwined with substance abuse.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Denial of mental health support for people in crisis with co-occurring substance abuse
Wider context from the report “Specialist dual diagnosis service needed with outreach facilities including drop-in and day centres to provide support for those in mental health crisis which is inextricably entwined with their substance abuse and who are often denied that mental health support .
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand alternative provision for people experiencing mental health crisis, including sanctuaries, safe havens and crisis cafes.
Verbatim wording from the response “We will also expand services for people experiencing a mental health crisis. As part of our COVID-19 response work, for those with severe needs or in crisis, all NHS mental health providers have established 24/7 urgent mental health helplines. In addition, under the NHS Long Term Plan, we will increase alternative forms of provision for those in crisis. Sanctuaries, safe havens and crisis cafes provide a more suitable alternative to A&E for many people experiencing mental health crisis, usually for people whose needs are escalating to crisis point, or who are experiencing a crisis but do not necessarily have medical needs that require A&E admission. These alternatives are commissioned through the NHS and local authorities, provided at relatively low cost and to high satisfaction, and usually delivered by voluntary sector partners.” Source location 2021-0360-Response-from-Dept.-of-Health-and-Social-Care_Published
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How this respondent action was interpreted
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PFD Monitor interpretation Invest £13 million to sustain and enhance 24/7 crisis lines during 2021/22.
Verbatim wording from the response “£58million of this extra £500million announced will be invested to bring forward the expansion of integrated primary and secondary care for adults with severe mental illness and £13million will be used for crisis support to sustain and enhance operation of 24/7 crisis lines in 2021/22.” Source location 2021-0360-Response-from-Dept.-of-Health-and-Social-Care_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a community-based mental health offer including psychological therapies, physical healthcare, employment support, personalised care, medicines management and support for self-harm and coexisting substance use.
Verbatim wording from the response “A new community-based offer will include access to psychological therapies, improved physical health care, employment support, personalised and trauma-informed care, medicines management and support for self-harm and coexisting substance use. This includes maintaining and developing new services for people who have the most complex needs and proactive work to address racial disparities. Local areas will be supported to redesign and reorganise community mental health teams to move towards a new place-based, multidisciplinary service across health and social care aligned with primary care networks.” Source location 2021-0360-Response-from-Dept.-of-Health-and-Social-Care_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve signposting and expand coverage of alternative mental health crisis services.
Verbatim wording from the response “While these services now exist in a number of areas, we will work to improve signposting, and expand coverage to reach more people and make a greater impact.” Source location 2021-0360-Response-from-Dept.-of-Health-and-Social-Care_Published
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24 Jun 2021 Amy Anne June Ganner · Prevention of Future Deaths report Manchester West
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Concerns raised 1 Risk of opioid toxicity following unpredictable loss of tolerance View source
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Amy Anne June Ganner · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Amy Anne June Ganner, who had complex health conditions and chronic pain, inadvertently ingested an excessive amount of prescribed medication before being discovered on 6 January 2021. The report identified concerns about the combined depressant effects of opioid medicines and the unpredictable loss of tolerance after abstinence; the inquest conclusion was misadventure and the medical cause of death was combined drugs toxicity.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Risk of opioid toxicity following unpredictable loss of tolerance
Wider context from the report “The deceased had suffered with chronic pain from complex medical conditions for several years. Her medication included Tramadol capsules; Zomorph modified release capsules and morphine sulphate oral solution all of which were opioid drugs associated with central nervous and respiratory depressant effects. Their individual effects would be enhanced when taken in combination and these depressant effects would be exacerbated by her use of the other drugs appropriately prescribed for her. As for all opiate cases the toxicological significance of the morphine concentration will depend upon the degree of tolerance possessed by the deceased. In this case as the opiate based medication was prescribed for her and being used regularly she would be expected to have a degree of tolerance. However it is known and was asserted in evidence that tolerances can be quickly lost, in the event of a period of abstinence ; that the diminution of tolerance varies from person to person and is extremely difficult to predict . Whilst the deceased was intelligent and had a clear understanding of the risks, benefits and role of her medication both her general practitioner who gave evidence and I believe that it would be extremely helpful if the Department of Health was to support the production of a leaflet in both electronic and paper formats dealing with the concept of ‘tolerance’ and emphasising the serious risk of toxicity which would be available to all whom are prescribed opiate based medication
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss with the MHRA how to improve access to opioid safety information leaflets.
Verbatim wording from the response “Furthermore, I will speak to the MHRA about how to improve access to their information leaflets, to ensure this information is as widely available as possible.” Source location 2021-0218-Response-from-Department-of-Health-and-Social-Care_Published
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10 Jun 2021 Clive Edward Rivers · Prevention of Future Deaths report Manchester South
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Concerns raised 3 Failure of the discharge assessment framework to account for vulnerability to rapid Covid-19 decline View source Delays in discharge planning and Right to Reside assessment View source Failure to provide Covid-19 vaccination to eligible inpatients View source
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AI-generated summary
Clive Edward Rivers · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Clive Edward Rivers was admitted to hospital after a fall, contracted Covid-19 while awaiting discharge, and died at home after being discharged to sheltered accommodation with a care package and a requirement to isolate. Concerns included his not being vaccinated while an inpatient, delays in discharge planning during which he contracted Covid-19, and an assessment framework that did not appear to account for his vulnerability to rapid deterioration while isolating at home.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of the discharge assessment framework to account for vulnerability to rapid Covid-19 decline
Wider context from the report “3. The inquest heard that when he was discharged from hospital, he was known to have Covid-19. He was assessed under the national right to reside policy and it was deemed under that policy that he should be discharged back to sheltered accommodation where he would have to self-isolate with carers coming in at set points in the day to support him. He was found deceased by his carers after being left alone. The assessment framework did not appear to take into account his vulnerability to a rapid decline from Covid-19 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in discharge planning and Right to Reside assessment
Wider context from the report “2. He tested negative for Covid-19 at the point he was medically optimised for discharge however delays in discharge planning including the required assessment under the Right to Reside policy meant that whilst awaiting discharge he contracted Covid-19 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Covid-19 vaccination to eligible inpatients
Wider context from the report “1. Clive Rivers was vulnerable to Covid-19 by reason of his age but had to go into hospital as a result of a fall. He had a longstanding skin condition that caused him a great deal of distress and discomfort. Whilst an inpatient he was prescribed immunomodulatory therapy and the consultant dermatologist wanted him to be vaccinated due to the increased risk Covid-19 presented to him both in terms of catching it and being able to recover from it. The inquest was told that whilst vaccines were available on the hospital site, they were at that time due to NHS policy only for staff not inpatients . Therefore, Mr Rivers was not vaccinated .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local organisations decide whether and where to offer hospital inpatients Covid-19 vaccination, within the JCVI’s prioritisation advice.
Verbatim wording from the response “Anyone in hospital and falling within the JCVI’s recommended groupings being invited for vaccination, would be eligible for the vaccine, subject to a clinical assessment of suitability on a case by case basis and local operational policies. While there is no national guidance preventing hospitals from vaccinating hospital inpatients, operational decisions on who to offer a vaccine to, and in what settings, are made locally, and in the context of the JCVI’s advice.” Source location 2021-0199-Response-from-Department-of-Health-Social-Care_Published.pdf
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21 May 2021 Martin Gibbons · Prevention of Future Deaths report Manchester South
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Concerns raised 5 Delays in cross-trust mental health bed allocation for patients outside the assessing trust’s commissioned area View source Lack of a shared definition of high-risk mental health patients between acute and mental health trusts View source Failure to provide detailed and documented shared risk assessments and care plans in acute settings View source Insufficient availability of mental health beds View source Lack of national or regional guidance for shared care planning View source See 2 more concerns
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AI-generated summary
Martin Gibbons · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Martin Gibbons attempted to take his own life on 19 March 2020 and was taken to hospital, where he was assessed as needing admission to a psychiatric ward. While waiting for a bed, he left the hospital unobserved and was found dead on 24 March 2020; the inquest concluded suicide. Concerns included differing assessments of risk between acute and mental health trusts, the absence of shared risk assessments and care plans, and delays in obtaining a mental health bed.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in cross-trust mental health bed allocation for patients outside the assessing trust’s commissioned area
Wider context from the report “3. It was during the prolonged wait in the Emergency Department for a mental health bed that Mr Gibbons left. The inquest heard that this wait was contributed to by a number of factors in particular
• A national lack of mental health beds;
• The fact that although he had presented to Tameside Hospital and had been assessed by Pennine Care staff because he was a resident of a neighbouring borough covered by a different NHS Mental Health Trust that other Trust had to be contacted ,given all of the information and find him a bed . The inquest was told that this was as a result of how services were commissioned and that the workers who had assessed him had no choice other than to follow this process notwithstanding the additional delay it created .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a shared definition of high-risk mental health patients between acute and mental health trusts
Wider context from the report “1. During the course of the inquest evidence was heard that the acute and mental health trusts involved had assessed the level of risk he presented differently in part due to there being no shared definition of risk or the factors that triggered a patient being treated as high risk . The inquest heard that across the NHS there is in relation to mental health no shared definition between acute and mental health trusts of what constitutes a high risk patient . The two trusts involved in this inquest had since Mr Gibbon’s death identified that as an issue and work was underway between them to develop and implement a shared definition locally in the absence of any shared national definition.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide detailed and documented shared risk assessments and care plans in acute settings
Wider context from the report “2. The inquest heard evidence that since Mr Gibbon’s death both trusts had recognised that to reduce risk there needed to be detailed and documented shared risk assessments and care plans for patients such as him in an acute setting . The inquest heard that there was no national or regional guidance in place in relation to this shared care plan approach.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of mental health beds
Wider context from the report “3. It was during the prolonged wait in the Emergency Department for a mental health bed that Mr Gibbons left. The inquest heard that this wait was contributed to by a number of factors in particular
• A national lack of mental health beds ;
• The fact that although he had presented to Tameside Hospital and had been assessed by Pennine Care staff because he was a resident of a neighbouring borough covered by a different NHS Mental Health Trust that other Trust had to be contacted ,given all of the information and find him a bed. The inquest was told that this was as a result of how services were commissioned and that the workers who had assessed him had no choice other than to follow this process notwithstanding the additional delay it created.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national or regional guidance for shared care planning
Wider context from the report “2. The inquest heard evidence that since Mr Gibbon’s death both trusts had recognised that to reduce risk there needed to be detailed and documented shared risk assessments and care plans for patients such as him in an acute setting. The inquest heard that there was no national or regional guidance in place in relation to this shared care plan approach .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Design and implement integrated care pathways linking liaison psychiatry teams with community mental-health services, including timely information sharing.
Verbatim wording from the response “All acute hospitals now have an adult liaison service in place, with 78 per cent of these services operating 24 hours a day, 7 days-a-week, which is an increase from 39 per cent in 2017, and this expansion is continuing through the NHS Long Term Plan. NHSE/I is working with local areas to design and implement care pathways that are integrated with the wider health and social care system, including timely sharing of information between liaison psychiatry teams and community mental health services.” Source location 2021-0166-Response-from-Department-of-Health-Social-Care_Published.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest an additional £500 million in 2021/22 to support mental-health service recovery, including expanded community, crisis and discharge-support services.
Verbatim wording from the response “You may also wish to note that, while we are emerging from the crisis period resulting from COVID-19, we continue to monitor the impact of the pandemic and adjust policy and investment priorities where necessary. The NHS will be investing significantly in mental health service capacity this year, with an additional £500million in 2021/22 to support recovery in mental health services on top of the funding already committed through the NHS Long Term Plan. This investment includes funding to bring forward existing plans to improve/expand community mental health services, crisis care services and support for people to be discharged from hospital in a timely manner. All of which should help to both reduce pressures on local inpatient services so that those who need to access beds can do so quickly and locally.” Source location 2021-0166-Response-from-Department-of-Health-Social-Care_Published.pdf
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Risk assessments should be personalised rather than based on shared definitions or standardised tools, which are poor predictors of suicide or specific behaviour.
Verbatim wording from the response “With regard to a shared definition of risk, evidence from the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH)¹, as well as National Institute for Health and” Source location 2021-0166-Response-from-Department-of-Health-Social-Care_Published.pdf
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local clinicians and operational managers are responsible for the safety of handover and patient management between acute and mental health services.
Verbatim wording from the response “Recently, (and in part due to concerns raised by your report) NHS England has asked all parts of the country to ensure that they have in place clear written protocols for escalation and actions to be taken when patients are waiting long periods, or a bed cannot be identified. The handover and management of a patient between services (in this case, acute and mental health services) is a local operational matter and the safety of these processes is the responsibility of the clinicians and operational managers involved in the direct care of the patient. There is a significant body of guidance that emphasises the importance of sharing patient information (which includes assessments and care plans) between clinical teams for the purposes of direct clinical care. National guidance³ on care for people with mental health needs in emergency departments has been published by NHS England.” Source location 2021-0166-Response-from-Department-of-Health-Social-Care_Published.pdf
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local NHS commissioners determine mental health bed provision based on local need and the effectiveness of community care.
Verbatim wording from the response “I have noted your concerns about the time taken to identify and confirm a mental health bed for Mr Gibbons. The provision of mental health beds is determined by local NHS commissioners, taking into consideration local need as well as the effectiveness of the local mental health system in providing access to care and support to people in the community, thereby reducing the requirement for admission to hospital. While in some local areas there may be a genuine need for more inpatient capacity, this should always be considered as part of whole system transformation to reduce over reliance on hospital-based care.” Source location 2021-0166-Response-from-Department-of-Health-Social-Care_Published.pdf
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19 May 2021 Richard Burgess · Prevention of Future Deaths report Sunderland
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Concerns raised 7 Failure to evidence or apply comprehensive assessments of the impact of a person’s difficulties View source Failure to provide a social environment supporting psychological and physical needs View source Failure to use a proactive dementia care model based on detailed assessment, intervention and evaluation of changing needs and risks View source Failure to provide individualised person-centred care from the person’s perspective View source Failure to convert policy into practice View source Lack of a multidisciplinary dementia care team with suitable skills, qualifications and competencies View source Failure to maintain continuous family engagement in the “triangle of care” View source See 4 more concerns
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AI-generated summary
Richard Burgess · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Richard Burgess died at Holy Cross Nursing and Residential Care Home, Sunderland, on 30 November 2018 after being punched three times in the head by another patient on 31 August 2018. The principal concerns related to dementia care, including multidisciplinary staffing, proactive assessment and risk management, family engagement, person-centred care, and converting policy into practice.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to evidence or apply comprehensive assessments of the impact of a person’s difficulties
Wider context from the report “I did not have a sufficient level of confidence about:
• the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care;
• a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication;
• the evidence of assessments or the application of assessments of the impact of a person’s difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person ;
• a continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories;
• a focus on the person, asserting absolute value of the person, in an individualised approach, while understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs;
• converting policy into practice.
The Trust had done a lot of work since the death of Mr Burgess, and I should also be pleased to hear from the Secretary of State about wider learning for other Trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a social environment supporting psychological and physical needs
Wider context from the report “I did not have a sufficient level of confidence about:
• the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care;
• a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication;
• the evidence of assessments or the application of assessments of the impact of a person’s difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person;
• a continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories;
• a focus on the person, asserting absolute value of the person, in an individualised approach, while understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs ;
• converting policy into practice.
The Trust had done a lot of work since the death of Mr Burgess, and I should also be pleased to hear from the Secretary of State about wider learning for other Trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to use a proactive dementia care model based on detailed assessment, intervention and evaluation of changing needs and risks
Wider context from the report “I did not have a sufficient level of confidence about:
• the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care;
• a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication ;
• the evidence of assessments or the application of assessments of the impact of a person’s difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person;
• a continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories;
• a focus on the person, asserting absolute value of the person, in an individualised approach, while understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs;
• converting policy into practice.
The Trust had done a lot of work since the death of Mr Burgess, and I should also be pleased to hear from the Secretary of State about wider learning for other Trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide individualised person-centred care from the person’s perspective
Wider context from the report “I did not have a sufficient level of confidence about:
• the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care;
• a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication;
• the evidence of assessments or the application of assessments of the impact of a person’s difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person;
• a continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories;
• a focus on the person, asserting absolute value of the person, in an individualised approach, while understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs;
• converting policy into practice.
The Trust had done a lot of work since the death of Mr Burgess, and I should also be pleased to hear from the Secretary of State about wider learning for other Trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to convert policy into practice
Wider context from the report “I did not have a sufficient level of confidence about:
• the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care;
• a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication;
• the evidence of assessments or the application of assessments of the impact of a person’s difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person;
• a continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories;
• a focus on the person, asserting absolute value of the person, in an individualised approach, while understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs;
• converting policy into practice .
The Trust had done a lot of work since the death of Mr Burgess, and I should also be pleased to hear from the Secretary of State about wider learning for other Trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a multidisciplinary dementia care team with suitable skills, qualifications and competencies
Wider context from the report “I did not have a sufficient level of confidence about:
• the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care ;
• a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication;
• the evidence of assessments or the application of assessments of the impact of a person’s difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person;
• a continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories;
• a focus on the person, asserting absolute value of the person, in an individualised approach, while understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs;
• converting policy into practice.
The Trust had done a lot of work since the death of Mr Burgess, and I should also be pleased to hear from the Secretary of State about wider learning for other Trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain continuous family engagement in the “triangle of care”
Wider context from the report “I did not have a sufficient level of confidence about:
• the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care;
• a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication;
• the evidence of assessments or the application of assessments of the impact of a person’s difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person;
• a continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories ;
• a focus on the person, asserting absolute value of the person, in an individualised approach, while understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs;
• converting policy into practice.
The Trust had done a lot of work since the death of Mr Burgess, and I should also be pleased to hear from the Secretary of State about wider learning for other Trusts.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue commissioning and funding training and programmes to recruit, develop and progress the social care workforce.
Verbatim wording from the response “Ensuring that we have a workforce that has the right values, skills and knowledge, is essential to providing a high-quality service for all those who have need of care services, including those living with dementia. This is why the Department continues to commission and fund a range of training opportunities and other programmes to help recruit people into the sector and develop career pathways, and to support staff to progress to more senior management and leadership roles.” Source location 2021-0163-Response-from-Department-of-Health-and-Social-Care_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the national Care Certificate training for newly appointed health and social care support workers.
Verbatim wording from the response “Since 1 April 2015, newly appointed health care assistants and social care support workers, including those providing care to people with dementia and their carers, have been undergoing training as part of the national implementation of the Care Certificate.” Source location 2021-0163-Response-from-Department-of-Health-and-Social-Care_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore options to increase uptake of Tier 2 dementia training among staff who require it.
Verbatim wording from the response “Good progress has been made to date in training the social care workforce, with around half of those estimated to require Tier 2 level training, having undertaken training to a level equivalent to it. The Department is currently exploring options for increasing uptake of Tier 2 training by everyone who needs it, and in March 2019, the Minister for Care co-signed a letter with the Chief Executive Officers of Skills for Care and Health Education England which was circulated to health and care organisations highlighting the importance of training.” Source location 2021-0163-Response-from-Department-of-Health-and-Social-Care_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver more person-centred, coordinated social care responsive to individual needs, promoting choice and maintaining independence.
Verbatim wording from the response “In summary, we recognise that personalised care is vital to those people that need care and support. It has demonstrated the ability to improve outcomes and enhance quality of life, enabling people to take control and responsibility for the things that are important to them as well as the care they need. Work is underway to deliver more person-centred, co-ordinated social care, that is responsive to individual needs, promotes choice, and maintains independence.” Source location 2021-0163-Response-from-Department-of-Health-and-Social-Care_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The NHS Foundation Trust is responsible for reflecting on the investigation findings and taking appropriate action to improve services.
Verbatim wording from the response “Finally, I expect the Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust to reflect on the findings of your investigation, and take appropriate action to strengthen and improve services. I am aware that the Trust has provided a response explaining the action it has taken following Mr Burgess’s death, particularly in relation to the way patient care is reviewed and monitored. I understand that the Trust’s strengthened review process now provides a more detailed analysis on each patient, which will assist multi-disciplinary teams to effectively plan care for dementia patients.” Source location 2021-0163-Response-from-Department-of-Health-and-Social-Care_Published
Open published response
Concerns raised 2 Lack of restrictions on the import, export, possession or administration of oral morphine View source Failure to apply safe custody and sign-for requirements to oral morphine View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Helen Spicer · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Helen Spicer died at Royal Cornwall Hospital Truro on 4 October 2018 from an unintentional overdose of prescription morphine, against a background of opiate dependency and chronic pain due to fibromyalgia. The report raised concerns about the absence of restrictions and safe-custody requirements for oral morphine, including the lack of a requirement for collection from a community pharmacy to be signed for.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of restrictions on the import, export, possession or administration of oral morphine
Wider context from the report “The absence of restrictions on the import, export, possession or administration of oral morphine , and the fact that safe custody requirements do not apply to them, including the need for them to be signed for when collecting from a community pharmacy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to apply safe custody and sign-for requirements to oral morphine
Wider context from the report “The absence of restrictions on the import, export, possession or administration of oral morphine, and the fact that safe custody requirements do not apply to them, including the need for them to be signed for when collecting from a community pharmacy .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Home Office takes decisions on controlled-drug scheduling, informed by advice from the Advisory Council on the Misuse of Drugs.
Verbatim wording from the response “Decisions on the scheduling of controlled drugs under the relevant legislation are taken by the Home Office. This is done with the provision of advice from the Advisory Council on the Misuse of Drugs (ACMD), and any decisions made by the ACMD weigh up the risks of misuse, abuse and diversion, against not impeding legitimate use within healthcare.” Source location 2021-0127-Response-from-Department-of-Health-and-Social-Care_Published
Open published response
30 Apr 2021 Rohan Dayal Singh · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Failure to maintain accurate records of clinical observations View source Tolerance of inaccurate and misleading clinical record keeping View source Failure of searches to detect and remove dangerous contraband View source Failure to undertake required intermittent observations View source Failure to complete relevant documentation after rapid tranquillisation View source Failure to monitor patients following rapid tranquillisation View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rohan Dayal Singh · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Rohan Dayal Singh died on a mental health ward on 13 December 2018 after being found unresponsive following rapid tranquillisation. He had retained dangerous contraband, including controlled drugs and a bracelet concealing a blade, despite searches. Fifteen-minute observation records were falsified, and required monitoring and documentation after rapid tranquillisation were not completed; the jury found that the failure to monitor contributed to his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate records of clinical observations
Wider context from the report “2. Mr Singh was subject to intermittent observations at 15 minute intervals during his admission. The records of these observations were found to be unreliable , staff accepted that they had failed to undertake observations and made false records , further they had done so in such circumstances that their peers were aware of the falsehood. A culture of impunity existed where inaccurate and misleading recording of clinical records was tolerated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Tolerance of inaccurate and misleading clinical record keeping
Wider context from the report “2. Mr Singh was subject to intermittent observations at 15 minute intervals during his admission. The records of these observations were found to be unreliable, staff accepted that they had failed to undertake observations and made false records, further they had done so in such circumstances that their peers were aware of the falsehood. A culture of impunity existed where inaccurate and misleading recording of clinical records was tolerated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of searches to detect and remove dangerous contraband
Wider context from the report “1. Rohan Singh died on a mental health ward, following his death he was found to be in possession of number of prohibited items including controlled drugs and a bracelet consisting of a ligature and a blade. Before admission into hospital, Rohan had been subject to a personal search by police officers when the bracelet was seized. During Rohan’s admission his property was subjected to a search and later he himself was searched for contraband, despite these steps he retained dangerous contraband.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake required intermittent observations
Wider context from the report “2. Mr Singh was subject to intermittent observations at 15 minute intervals during his admission. The records of these observations were found to be unreliable, staff accepted that they had failed to undertake observations and made false records, further they had done so in such circumstances that their peers were aware of the falsehood. A culture of impunity existed where inaccurate and misleading recording of clinical records was tolerated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to complete relevant documentation after rapid tranquillisation
Wider context from the report “3. Mr Singh was subject to rapid tranquillisation, following administration of this medication, staff failed to follow the Trust’s monitoring process or complete relevant documentation . The failure to monitor Rohan was found by the jury to have contributed to his death. Trust evidence demonstrates that beyond this incident, throughout the organisation the processes are not being universally followed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor patients following rapid tranquillisation
Wider context from the report “3. Mr Singh was subject to rapid tranquillisation, following administration of this medication, staff failed to follow the Trust’s monitoring process or complete relevant documentation. The failure to monitor Rohan was found by the jury to have contributed to his death. Trust evidence demonstrates that beyond this incident, throughout the organisation the processes are not being universally followed.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Professional concerns about nurses’ conduct and registration are for the NMC to investigate and sanction.
Verbatim wording from the response “The Nursing and Midwifery Council (NMC) have informed the Department it will be providing a separate response to you in relation to this case. The NMC code of practice² sets out the professional standards that nurses, midwives and nursing associates must uphold in order to be registered to practise in the UK.” Source location 2021-0134-Response-from-Department-of-Health-Social-Care_Published
Open published response
30 Apr 2021 Joanna Leven · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Gaps in statutory provision of trauma-, violence- and domestic-abuse-specific counselling and mental health services View source Lack of a consistent therapeutic pathway and therapy availability for Personality Disorders View source Failure of Hospital and Mental Health Liaison records systems to support complete information sharing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joanna Leven · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joanna Leven was found dead at home on 26 March 2020 after self-induced asphyxia, following a deterioration in her mental health after her dog became seriously unwell and was euthanised. The report identified concerns about the absence of a comprehensive mental health assessment, variable access to therapeutic pathways and trauma-focused services, and the risk of information being lost between hospital and mental health liaison records systems.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Gaps in statutory provision of trauma-, violence- and domestic-abuse-specific counselling and mental health services
Wider context from the report “2) Evidence was heard in court to the effect that there are gaps in provision by statutory agencies of counselling and other mental health services specifically tailored for victims of trauma, violence and domestic abuse . In Stockport, specialist services of this nature fall to be provided by a registered charity with only short-term funding in place, a position which is understood to be replicated elsewhere in the country;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a consistent therapeutic pathway and therapy availability for Personality Disorders
Wider context from the report “1) The court heard evidence that there is no national therapeutic pathway for treatment of Personality Disorders . Whilst the court heard steps are in place to introduce a local pathway for residents of Greater Manchester, it is understood eligibility for and availability of various therapies which may be beneficial to patients diagnosed with a Personality Disorder varies from place to place ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of Hospital and Mental Health Liaison records systems to support complete information sharing
Wider context from the report “3)The court heard evidence that, where a patient attends a Hospital Emergency Department with both physical and mental health needs, it is usually the case that Hospital and Mental Health Liaison staff are working with different computer-based records systems . This creates an obvious risk of information being lost or incompletely conveyed as between different professional groups .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Redesign community mental health provision through integrated, place-based multidisciplinary services aligned with primary care networks.
Verbatim wording from the response “Under the NHS Long Term Plan, we are investing almost £1billion extra in community mental health care for adults by 2023/24. New and integrated models of primary and community mental health care will give 370,000 adults with serious mental illnesses, including personality disorders, greater choice and control over their care and support them to live well in their communities by 2023/24.” Source location 2021-0126-Response-from-Dept.-of-Health-Social-Care_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £40 million in 2021/22 to strengthen specialist support services for victims of rape and domestic abuse, including community services and adviser recruitment.
Verbatim wording from the response “We continue to take steps nationally to ensure that victims of abuse and domestic abuse have timely access to care and support. As laid out in the recovery action plan, the Government is providing £40million in 2021/22 to boost specialist support services for victims of rape and domestic abuse. This includes: over £20million for local community-based sexual violence and domestic abuse services, to help reduce the amount of time survivors wait for support; £16million to recruit more independent sexual violence and domestic abuse advisers; and £2million for smaller, specialist organisations that help ethnic minority, LGBT or disabled victims.” Source location 2021-0126-Response-from-Dept.-of-Health-Social-Care_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest almost £1 billion in adult community mental health care by 2023/24.
Verbatim wording from the response “Under the NHS Long Term Plan, we are investing almost £1billion extra in community mental health care for adults by 2023/24. New and integrated models of primary and community mental health care will give 370,000 adults with serious mental illnesses, including personality disorders, greater choice and control over their care and support them to live well in their communities by 2023/24.” Source location 2021-0126-Response-from-Dept.-of-Health-Social-Care_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local clinical commissioning groups are responsible for decisions about commissioning mental health services for local populations.
Verbatim wording from the response “In relation to commissioning mental health services for victims of trauma, violence and domestic abuse, local clinical commissioning groups are responsible for decisions about commissioning services to meet the needs of their local populations. Services may be provided by a range of organisations, including NHS and private providers, and providers in the voluntary, community and social enterprises.” Source location 2021-0126-Response-from-Dept.-of-Health-Social-Care_Published
Open published response
26 Apr 2021 Alan Massam · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Limited understanding of when and how to use s.9 assessments for vulnerable adults View source Lack of clear inter-agency information-sharing arrangements for complex care View source Lack of a defined escalation process for refusal of medication and fluids View source Shortage of suitable adult care beds for complex cases View source Continuation of care in a home unable to safely meet complex care needs View source Lack of guidance on ensuring a care home can accept a person back after discharge View source Lack of guidance on acute trust action when attempts to contact a care home are unsuccessful View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alan Massam · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alan Massam, a resident with dementia, had repeated falls after moving to a dementia residential home and was twice admitted to hospital. After a traumatic brain bleed and rib fractures were identified, he deteriorated and died in hospital on 24 October 2019. Concerns included inadequate information-sharing between agencies, discharge without effective communication or confirmation that the care home could meet his needs, and the absence of a clear escalation process when he refused medication and fluids.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Limited understanding of when and how to use s.9 assessments for vulnerable adults
Wider context from the report “1. The inquest heard that the care of Mr Massam was complex due to his needs but there was no clear agreement or arrangement between agencies as to how to effectively share information in complex cases.in his case mental health services were involved as was the acute trust, GP and the care home but there was limited evidence of a joint approach to ensure his care was optimised. This included a limited understanding by those involved of when and how to use of s.9 assessments to reduce the risk to a vulnerable adult such as Mr Massam.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clear inter-agency information-sharing arrangements for complex care
Wider context from the report “1. The inquest heard that the care of Mr Massam was complex due to his needs but there was no clear agreement or arrangement between agencies as to how to effectively share information in complex cases .in his case mental health services were involved as was the acute trust, GP and the care home but there was limited evidence of a joint approach to ensure his care was optimised . This included a limited understanding by those involved of when and how to use of s.9 assessments to reduce the risk to a vulnerable adult such as Mr Massam.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a defined escalation process for refusal of medication and fluids
Wider context from the report “3. The staff at the home were aware of the prescribing of medication including antibiotics. However when he refused them and fluids there was no defined escalation process which would ensure that the risk this presented was recognised and acted on .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Shortage of suitable adult care beds for complex cases
Wider context from the report “4. Once the initial home could not manage Mr Massam and served a notice on the family there was a significant pressure to find another home that would accept him. Whilst the search was undertaken he remained in a home where staff felt they could no longer safely meet his care needs. The inquest heard that this search was exacerbated by a national shortage of suitable beds within the adult care sector for complex cases such as Mr Massam .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Continuation of care in a home unable to safely meet complex care needs
Wider context from the report “4. Once the initial home could not manage Mr Massam and served a notice on the family there was a significant pressure to find another home that would accept him. Whilst the search was undertaken he remained in a home where staff felt they could no longer safely meet his care needs . The inquest heard that this search was exacerbated by a national shortage of suitable beds within the adult care sector for complex cases such as Mr Massam.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on ensuring a care home can accept a person back after discharge
Wider context from the report “2. Mr Massam was discharged back to the care home by the acute trust. The inquest heard that the home would not have accepted him back if they had been spoken to as they did not feel they could meet his needs. The inquest heard that there is no national guidance/protocol about what an acute trust should do if attempts to contact a home are unsuccessful or about the obligation to ensure the home can accept him back in such circumstances as these.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on acute trust action when attempts to contact a care home are unsuccessful
Wider context from the report “2. Mr Massam was discharged back to the care home by the acute trust. The inquest heard that the home would not have accepted him back if they had been spoken to as they did not feel they could meet his needs. The inquest heard that there is no national guidance/protocol about what an acute trust should do if attempts to contact a home are unsuccessful or about the obligation to ensure the home can accept him back in such circumstances as these.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue driving health and social care integration by removing data-sharing barriers and enabling joint decision-making.
Verbatim wording from the response “I wish to reassure you that promoting integrated care is a priority for this Government. We are continuing to drive increased integration between health and social care by removing barriers to data sharing and enabling joint decision-making.” Source location 2021-0120-Response-from-Dept-of-Health-Social-Care-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide councils access to more than £1 billion of additional social care funding for 2021–22.
Verbatim wording from the response “We support local authorities to manage their local markets effectively and are providing councils with access to over £1 billion of additional funding for social care in 2021-22.” Source location 2021-0120-Response-from-Dept-of-Health-Social-Care-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and update the Hospital Discharge Service policy and operating model guidance for NHS trusts and care home providers.
Verbatim wording from the response “National guidance is available to support local health and care systems to facilitate good practice when patients are discharged from hospital. In March 2020, we published – and have since updated – the Hospital Discharge Service: policy and operating model⁴ guidance for NHS Trusts and care home providers, although this guidance predominantly applies to the discharge of patients who have been admitted to hospital, which does not appear to be the case here.” Source location 2021-0120-Response-from-Dept-of-Health-Social-Care-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local authorities are responsible for shaping markets and ensuring adequate adult social care provision for residents with complex needs.
Verbatim wording from the response “You also raise the matter of available adult social care beds for residents with complex care needs. Local authorities are best placed to understand and plan for the care needs of their populations. That is why under the Care Act 2014, local authorities are required to shape their local markets, and ensure that people have a range of high-quality, sustainable and person-centred care and support options available to them, and that they can access the services that best meet their needs. This includes ensuring adequate local provision of adult social care beds for residents with complex needs.” Source location 2021-0120-Response-from-Dept-of-Health-Social-Care-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The relevant Safeguarding Adults Board may undertake a review to identify learning and improvement actions across local agencies.
Verbatim wording from the response “The Act requires each local authority to establish a Safeguarding Adults Board (SAB) to provide assurance that local safeguarding arrangements and partners are acting to support and protect adults who may be at risk of abuse or neglect. These Boards have the authority to carry out a Safeguarding Adult Review (SAR) in instances when serious harm or a fatality has occurred and there is concern that providers could have worked more effectively to have better protected the vulnerable adult.” Source location 2021-0120-Response-from-Dept-of-Health-Social-Care-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation When patients refuse prescribed medication or fluids, their GP should decide the appropriate next steps.
Verbatim wording from the response “I understand that the Greater Manchester Health and Social Care Partnership recommends that where a patient is not accepting prescribed medication or fluids, then contact should be made to the patient’s GP so that a decision can be made in relation to next steps.” Source location 2021-0120-Response-from-Dept-of-Health-Social-Care-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hospital discharge guidance predominantly applies to admitted patients, and this case did not appear to involve hospital admission.
Verbatim wording from the response “In relation to communication between acute hospitals and care homes at the point of discharge, I understand from your report that Mr Massam was seen and treated within the emergency department at Stepping Hill Hospital, Stockport before returning to Lisburne Court residential home the same day. Mr Massam was not admitted to hospital and I understand from information provided by the CQC that the hospital was unaware of any concerns about the home being unable to continue to meet Mr Massam’s care needs.” Source location 2021-0120-Response-from-Dept-of-Health-Social-Care-Redacted
Open published response
20 Apr 2021 Ella Adoo-Kissi-Debrah · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Insufficient undergraduate teaching on the health effects of air pollution View source Insufficient postgraduate education on the health effects of air pollution View source Insufficient detail and monitoring capacity for air quality information View source Insufficient professional guidance on communicating the health effects of air pollution View source Low public awareness of sources of national and local pollution information View source National Particulate Matter limits exceeding WHO guideline levels View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ella Adoo-Kissi-Debrah · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ella Adoo-Kissi-Debrah died aged 9 after an asthmatic episode led to cardiac arrest on 15 February 2013. The report states that air pollution, including exposure to nitrogen dioxide and particulate matter from traffic emissions, significantly contributed to her asthma and death. It also identifies concerns about pollution limits, public access to pollution information, and communication of air-pollution health risks by healthcare professionals.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient undergraduate teaching on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient postgraduate education on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail and monitoring capacity for air quality information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government. The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient professional guidance on communicating the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Low public awareness of sources of national and local pollution information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government . The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation National Particulate Matter limits exceeding WHO guideline levels
Wider context from the report “(1) The national limits for Particulate Matter are set at a level far higher than the WHO guidelines. The evidence at the inquest was that there is no safe level for Particulate Matter and that the WHO guidelines should be seen as minimum requirements. Legally binding targets based on WHO guidelines would reduce the number of deaths from air pollution in the UK.
” Open source report
15 Apr 2021 Ailsa Stewart · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of national guidance prescribing when domiciliary care packages can be suspended View source Lack of specific rules allocating agency responsibilities for conveying information when vulnerable patients are sent home from urgent care without admission View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ailsa Stewart · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ailsa Stewart, who was bed-bound, lived alone and relied on domiciliary carers, was left without domiciliary care after her care package was suspended following a hospital assessment. She was found gravely ill at home on 29 April 2019 and subsequently died in hospital; the inquest recorded that her death was from natural causes, contributed to by neglect. The report identified concern that there was no cohesive national framework or guidance governing suspension of domiciliary care packages and the communication of responsibilities between agencies.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance prescribing when domiciliary care packages can be suspended
Wider context from the report “The court heard evidence as to an extensive range of actions which local agencies have taken in response to Ms Stewart’s death to try and reduce the risk of a similar set of circumstances occurring again. That said, it was clear from the evidence that in England, family members play an essential part in ensuring continuity of care is maintained by sharing information between different agencies, and facilitating the co-ordination of care provided to vulnerable patients, particularly in circumstances where unplanned hospital attendances are required.
It is a matter of concern that no cohesive national framework or guidance exists across health and social care, to prescribe the circumstances in which a domiciliary care package can be suspended , or sets out specific rules as to the roles and responsibilities of particular agencies to convey information when a vulnerable patient is sent home from an urgent care setting without having formally been admitted.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of specific rules allocating agency responsibilities for conveying information when vulnerable patients are sent home from urgent care without admission
Wider context from the report “The court heard evidence as to an extensive range of actions which local agencies have taken in response to Ms Stewart’s death to try and reduce the risk of a similar set of circumstances occurring again. That said, it was clear from the evidence that in England, family members play an essential part in ensuring continuity of care is maintained by sharing information between different agencies, and facilitating the co-ordination of care provided to vulnerable patients, particularly in circumstances where unplanned hospital attendances are required.
It is a matter of concern that no cohesive national framework or guidance exists across health and social care, to prescribe the circumstances in which a domiciliary care package can be suspended, or sets out specific rules as to the roles and responsibilities of particular agencies to convey information when a vulnerable patient is sent home from an urgent care setting without having formally been admitted .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Because the patient was technically not admitted, the Trust did not need to invoke its hospital discharge process.
Verbatim wording from the response “NHSE and NHSI have informed my officials that technically Ms Stewart had not been admitted to hospital and it was therefore not necessary for the Trust to invoke their discharge process.” Source location 2021-0110-Response-from-Department-of-Health-Social-Care-Redacted
Open published response
13 Apr 2021 NATASHA JENNIFER IRENE CRABB · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Lack of restriction on the quantity of butane gas that can be purchased View source Lack of legal powers to prevent capable people inhaling butane or remove butane from them View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
NATASHA JENNIFER IRENE CRABB · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Natasha Jennifer Irene Crabb died at Princess Gardens, Woking, on 29 June 2018 after continuing to inhale butane gas following her self-discharge from hospital. The substantive concerns were that inhaling butane was lawful, there were no legal powers to prevent a person with capacity from inhaling it or to remove it from them, and there was no restriction on the amount of butane that could be purchased.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of restriction on the quantity of butane gas that can be purchased
Wider context from the report “2. There is no restriction on the amount of butane gas that can be purchased making it easy for a person addicted to inhaling butane gas to obtain large amounts of the gas at one time.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of legal powers to prevent capable people inhaling butane or remove butane from them
Wider context from the report “1. Inhaling butane is lawful and there are no legal powers to prevent a person with capacity inhaling butane nor to remove butane from them. The effects of inhalation can be fatal.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Home Office is responsible for responding on powers applicable under the Psychoactive Substances Act 2016.
Verbatim wording from the response “Departmental officials have made contact with the Home Office, which will be providing a response to you in relation to the powers applicable under the Psychoactive Substances Act 2016.” Source location 2021-0103-Response-from-Dept.-of-Health-and-Social-Care-Redacted
Open published response
Concerns raised 5 Failure to provide assurance that patient-safety surveys inspect each relevant bedroom for hazards such as ligature points View source Incomplete Risk Assessment/Safety Summary process for assessing and protecting patients View source Failure to print medical notes and other documents from the Trust IT system in shared premises View source Failure to upload PDF medical records and important information promptly in original form to the electronic notes system View source Limited coverage of the Bed Manager function to one Trust region View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mina TOPLEY-BIRD · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mina TOPLEY-BIRD, who had a severe and enduring mental illness and a history of suicide and self-harm attempts, was admitted to West Park Hospital after attempting to run into traffic and stab herself. On 8 May 2019, after being told that no bed was available for her in London, she said words to the effect of “I may as well kill myself”; she was later found hanging in her room and pronounced dead. Concerns included incomplete access to historic medical records, inability to print and share documents across NHS Trust systems, uncertainty about ligature-point assessments, limited bed-management coverage, and incomplete risk-assessment and safety-summary processes.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide assurance that patient-safety surveys inspect each relevant bedroom for hazards such as ligature points
Wider context from the report “3. The Trust (TEWV) in evidence heard that the Elm Ward at West Park Hospital had been surveyed for issues related to patient safety such as ligature points. Whilst the evidence was that the Trust was confident this had been done, no assurance could be given . One such assessment did not show clearly if the deceased's bedroom had been inspected for issues such as ligature points .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Incomplete Risk Assessment/Safety Summary process for assessing and protecting patients
Wider context from the report “5. The Trust gave evidence that the Risk Assessment/Safety Summary process for assessing and protecting patients had been improved, but accepted it was still 'a work in progress' and further work was required . It is of concern that this aspect of area of patient safeguarding appears on the evidence given at inquest not to be complete .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to print medical notes and other documents from the Trust IT system in shared premises
Wider context from the report “2. It became apparent on the evidence that whilst Trust staff were working in premises operated by another Trust (in this case, County Durham and Darlington NHS Foundation Trust - CDDFT) they could not print medical notes and other documents from the TEWV IT system onto printers in 'shared' premises such as the A&E Department of the CDDFT . This again meant important documents can be unable to be shared with staff undertaking such tasks as Mental Health Assessments .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to upload PDF medical records and important information promptly in original form to the electronic notes system
Wider context from the report “1. Evidence was heard that medical records and other important information could not be uploaded to the Trust's electronic notes system - PARIS when received in PDF form . This meant staff had to precis notes onto the system, in this case when one person was working alone, on a nightshift was required to do this whilst dealing with a variety of different tasks. Important documents that cannot not to be uploaded immediately and in their original form concerns me that attending clinicians do not have access to these documents and can be hindered in making clinical decisions without them .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Limited coverage of the Bed Manager function to one Trust region
Wider context from the report “4. Evidence was heard that within the Durham & Darlington area of the TEWV Trust funding had been secured for the post of a Bed Manager, who was to manage bed allocation, transfer and discharges to better manage access to beds for patients across this area of the Durham & Darlington area of the Trust. It was heard this role would be able to more proactively arrange transfers of patients from Trust to Trust as was a need raised in this inquest. It was disclosed that this post only operated in the Durham & Darlington area of the Trust and not across the whole Trust . On the evidence heard this post has obvious benefits for ensuring patients access to beds and I raise a concern this post is not one which cover the whole of the Trust, only one region of it .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enforcement action was not required because the regulator concluded there was no ongoing risk to service users.
Verbatim wording from the response “My officials also approached the Care Quality Commission (CQC). The CQC has sought assurances from the Trust in relation to its investigation and has concluded that there is no ongoing risk to service users and that enforcement action was not required.” Source location 2021-0100-Response-from-Dept.-of-Health-and-Social-Care-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operational processes for locally commissioned mental health services are the responsibility of local NHS providers and their commissioning partners.
Verbatim wording from the response “Mental health services provided by TEWV are locally commissioned and therefore operational processes, such as those described, are the responsibility of local NHS providers and their clinical commissioning group (CCG) system partners, which commission the services.” Source location 2021-0100-Response-from-Dept.-of-Health-and-Social-Care-Redacted
Open published response
31 Mar 2021 Joan Mavis COLEY · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 6 Lack of doctors' understanding of taking bloods from central lines and associated risks View source Failure to formally assess junior doctors' competence to take bloods from central lines View source Failure to formally assess and monitor doctors' procedural competence View source Limited medical school training on taking bloods from central lines and associated risks View source Failure to hand over junior doctors' procedural competencies between wards View source Lack of a standard written procedure for taking bloods from central lines View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Joan Mavis COLEY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joan Mavis COLEY, who had end stage renal failure requiring dialysis, diabetes and an infected right foot, suffered a cardiac arrest after air entered her central dialysis line while blood was being taken. She was resuscitated but subsequently developed sepsis and died on 27 November 2020. The principal concerns were inadequate training, supervision, competency assessment and handover for junior doctors taking blood from central lines, together with the absence of a clear standard operating procedure.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of doctors' understanding of taking bloods from central lines and associated risks
Wider context from the report “5. General understanding of the process to follow when taking blood from a central line and the associated risks: The inquest heard how there was a general lack of understanding of how to take bloods from a central line and the associated risks . The basic physiology was not understood and the consultant also did not know how to take blood from this central line . Consideration should be given to ensuring all doctors are fully aware of the basic principles when taking bloods from a central line and the associated risks.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to formally assess junior doctors' competence to take bloods from central lines
Wider context from the report “2. Induction programme for FY1 Doctors and assessment of base line competencies: The inquest heard how taking bloods from a central line is not part of the "check list" of tasks that junior doctors have to undertake . As a result there was no process in place to check whether an individual doctor was competent take bloods from a central line . This is inherently unsafe. Consideration should be given to adding "taking bloods from a central line" to the checklist of tasks.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to formally assess and monitor doctors' procedural competence
Wider context from the report “3. How to effectively assess and monitor competencies to undertake procedures: The inquest heard how there was no formal system for assessing a doctor's competence to undertake a particular task for example, taking bloods from a central line. The doctor would learn on the job with no formal training or assessment . When moving wards if a doctor agreed to undertake a procedure it was assumed they were competent and competent . This is inherently unsafe. The inquest heard how nurses have stringent criteria and training before they can handle any procedures. Consideration should be given to a similar process for junior doctors.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Limited medical school training on taking bloods from central lines and associated risks
Wider context from the report “1. Medical school training: The inquest heard evidence that there is very limited training on how to take bloods from a central line, the physiology involved and potential risks . The junior doctor in question did not feel she had adequate knowledge of the potential risk associated with the task she was undertaking. Urgent action is required to review what training is provided to medical students regarding taking bloods from central lines.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to hand over junior doctors' procedural competencies between wards
Wider context from the report “4. Handover of competencies from ward to ward: The inquest heard how there was no system of hand over when junior doctors change from ward to ward . The junior doctor in this case was shadowing on a new ward and the Consultant in charge had no understanding of the doctors level of ability or competency . Consideration should be given to having a system to hand over ability and competencies.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a standard written procedure for taking bloods from central lines
Wider context from the report “6. Standard operating procedures for taking bloods from central lines: The inquest heard how there was no standard written procedure for taking bloods from a central line . Consideration should be given to having a national standard procedure, which should be linked with training and assessment of competency for doctors to take bloods from a central line.
” Open source report
25 Mar 2021 Sheldon Gary Farnell · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 5 Failure to provide families’ contact details at hospital admission and discharge View source Outdated guidance and protocols for recognition of sepsis View source Failure of messaging to support timely and prompt antibiotic prescribing View source Failure to deliver sepsis training through doctors with relevant current expertise View source Lack of mandatory sepsis training View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sheldon Gary Farnell · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sheldon Gary Farnell, aged 4 years, died at Sunderland Royal Hospital on 26 November 2018 after presenting very unwell and being admitted to hospital. He was discharged before antibiotics could be given for adverse blood test results, and he could not be recalled. The concerns included sepsis recognition and training, the timely prescribing of antibiotics, and providing families with contact details at admission and discharge.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide families’ contact details at hospital admission and discharge
Wider context from the report “4. Contact details for families need to be positively given (not confirmed) at the time of admission and discharge within a hospital setting .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Outdated guidance and protocols for recognition of sepsis
Wider context from the report “1. Guidance for the recognition of sepsis may be in need of expedited revision with protocols reflecting up to date NICE guidelines .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of messaging to support timely and prompt antibiotic prescribing
Wider context from the report “3. The messaging about the timely and prompt prescribing of antibiotic medication is in need of a review , as the Inquest highlighted issues of a possible overly cautious approach in their use, when there was no impediment to such use , and they may have saved Sheldon’s life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to deliver sepsis training through doctors with relevant current expertise
Wider context from the report “2. Sepsis training should be mandatory and delivered by doctors with relevant experience of current research and guidance .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory sepsis training
Wider context from the report “2. Sepsis training should be mandatory and delivered by doctors with relevant experience of current research and guidance.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with NHS Trusts to design policies and best practice for improving sepsis diagnosis and management.
Verbatim wording from the response “The Government continues to work closely with NHS Trusts to design policies and best practice for improving the diagnosis and management of sepsis. Public Health England and NHSEI have recently developed a prototype for real time patient level data. We are committed to developing data linkage of infection, treatment and resistance histories to optimise life-saving treatments for serious infections, including sepsis.
We understand what a fast moving and complex area of diagnosis sepsis can be. Sepsis is not a single disease but a syndrome, has no specific diagnostic test or standard case definition and presentation can vary. As a result, we recognise it can be difficult to recognise and diagnose.” Source location 2021-0081-Response-from-Dept.-of-Health-Social-Care_Published
Open published response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Whether sepsis training should be mandatory is an employer decision, rather than a matter determined by the responding body.
Verbatim wording from the response “Regarding whether sepsis training should be mandatory, this is currently an employer decision, and I note the action taken by the South Tyneside and Sunderland NHS Foundation Trust to introduce multidisciplinary training for medical and nursing staff involved in the acute paediatric care and mandatory three-yearly sepsis training updates.” Source location 2021-0081-Response-from-Dept.-of-Health-Social-Care_Published
Open published response
18 Mar 2021 Bruce Lee Houghton · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Failure to complete annual medication reviews View source Failure to ask patients about over-the-counter medication during medication reviews View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Bruce Lee Houghton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Bruce Lee Houghton died at home on 16 April 2020 from combined drug toxicity, with excess paracetamol likely causing liver damage and accumulation of his other medications. The report states that he had not had his annual medication review, and that these reviews did not ask patients about over-the-counter medicines they purchased in addition to prescribed medication.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to complete annual medication reviews
Wider context from the report “2. The Court heard the deceased had not had his annual medication review . The court heard evidence that at these reviews the patients are not asked about any over the counter medication they may purchase in addition to their prescribed medication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ask patients about over-the-counter medication during medication reviews
Wider context from the report “2. The Court heard the deceased had not had his annual medication review. The court heard evidence that at these reviews the patients are not asked about any over the counter medication they may purchase in addition to their prescribed medication .
” Open source report
Concerns raised 7 Unavailability of consultant-level psychiatric input to eating disorder services View source Inadequate training and knowledge of eating disorders among medical professionals View source Under-reporting and inadequate recording and investigation of eating-disorder-related deaths View source Lack of robust and reliable prevalence data for eating disorders View source Shortage of eating disorder specialists View source Lack of formally commissioned monitoring provision for moderate to high risk Anorexia Nervosa patients View source COVID-19 pandemic exacerbation of eating disorder safety deficiencies View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Averil Hart · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Averil Hart died from anorexia nervosa on 15 December 2012, after severe weight loss and deterioration following her discharge from specialist eating-disorder treatment. The report identified concerns about inadequate monitoring and coordination of care, insufficient eating-disorder training and specialist provision, failures to provide nutritional support, delays and miscommunication in hospital care, inadequate data on eating-disorder prevalence and deaths, and the impact of the COVID-19 pandemic.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of consultant-level psychiatric input to eating disorder services
Wider context from the report “(2) Lack of formally commissioned service level agreement for the provision of robust and effective monitoring of moderate to high risk AN patients by primary or secondary care providers
Evidence confirmed that in response to the PHSO Report an Expert Reference Group (ERG) was convened by NHS England (NHSE) to address the specific recommendation for NHSE to review the existing quality and availability of services to achieve parity for adult ED services with children and young people’s ED services. The National Collaborating Centre for Mental Health (NCCMH) was commissioned to develop new guidance published in August 2019: “Adult Eating Disorders: Community, Inpatient and Intensive Day Patient Care – Guidance for Commissioners and Providers”.
However, the clear and unchallenged evidence received at Averil’s inquest confirmed that there remains a lack of formally commissioned provision for the monitoring of AN patients in primary or secondary care across large parts of the United Kingdom. Whilst the evidence received indicated that Cambridgeshire & Peterborough NHS Foundation Trust are seeking to develop models to ensure the provision of medical monitoring for all ED sufferers, including moderate to high risk patients, there are many areas in the country – including parts of the East of England Region – which still have no such formally commissioned provision. Further, unchallenged evidence identified a number of regions as not even having consultant level psychiatric in-put to the ED services that are purportedly available .
There was unanimity on the part of each of the senior clinicians who gave evidence, as well as a number of independent, instructed experts in the fields of ED and AN, that the continued absence of such monitoring and treatment provision gave rise to not only the risk of avoidable future deaths, but - in the views of many - the inevitability of the same. Evidence confirmed that whilst AN has the highest mortality of any mental disorder affecting young people and adults this should not be simply accepted and that AN and other EDs are treatable mental disorders, with even severe complications such as malnutrition safely reversible. The evidence further established that whilst in the long term primary prevention strategies including early recognition and treatment of the disease was critical, in the short to medium term, improving access to treatment and the effective monitoring of the severely ill is to be regarded as essential to address the risk of avoidable future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate training and knowledge of eating disorders among medical professionals
Wider context from the report “(1) Inadequate training of doctors and other medical professionals re eating disorders
Evidence from a wide range of clinicians who had engaged with Averil in 2012 echoed the evidence of clinicians attending the four inquests of the women referred to above. All five inquests revealed a common theme of wide-spread and continuing lack of training, knowledge, or experience on the part of physicians and medical staff (including GPs and nurse practitioners, as well as acute hospital doctors, nurses and dieticians) regarding eating disorders (EDs) and specifically Anorexia Nervosa (AN). Many witnesses (from both the death 2012 and those in 2017/2018) conceded that they had only the most superficial knowledge of the often complex issues relating to recognition, monitoring, management and treatment of EDs and AN specifically. Their evidence often reflected a lack of familiarity with the King’s College Guidance for the treatment of AN in the community. The evidence of hospital staff revealed, at best, inconsistent implementation of the Royal College of Psychiatrists MARSIPAN guidance for the emergency treatment of AN patients and, at worst, a failure to implement the Guidance at all .
Evidence at Averil’s inquest (and at those of ████████) suggested that limited progress has been made in respect of the PHSO recommendation with regard to the training of doctors and other medical professionals, (notwithstanding the further recommendations of the PACAC Follow-up Report and the Government Response to the latter’s Recommendations). These concerns have been reiterated by the Position Statement of the Royal College of Psychiatrists (PS04/20) of September 2020 “Improving core skills and competence in risk assessment and management of people with eating disorders: What all doctors need to know.”
The evidence at inquest of senior practitioners in the fields of psychiatry, psychology, acute medicine, dietetics, gastroenterology and GP practice all confirmed that there remains, as there was in 2012, a continuing and serious shortage of eating disorder specialists across the country with many Trusts finding it difficult to fill vacancies; such shortages inevitably impact upon the level and quality of support available to primary care providers and other specialists and therefore, in my view, risks avoidable future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Under-reporting and inadequate recording and investigation of eating-disorder-related deaths
Wider context from the report “(3) Lack of robust and reliable data regarding the prevalence of eating disorders
Evidence also confirmed that the lack of precise information on the prevalence of eating disorders in the United Kingdom, described by the PHSO Report and the PACAC Follow-up Report as “shocking, given the claim that up to 1.25 million people are suffering from an eating disorder and the fact that eating disorders have the highest mortality rate of mental illnesses” persists. The witness evidence also confirmed the view expressed in the PACAC Report. “This vagueness limits the ability of NHS commissioners to gauge what services need to be provided and encourages them to devote resources to better recorded diseases.”
Further, I am concerned that there may also be a significant under-reporting of the extent to which EDs have caused or contributed to deaths , leading to cases either not being referred to the coroner or, if they are, the coroner in question determining that death was one of ‘natural causes’, with only the terminal cause of death, and not the underlying ED cause or contribution to the death, being recorded . In such circumstances there is a concern that a number of such deaths (where, for example, lack of care may have contributed to the death) are neither investigated appropriately by the coroner nor taken to inquest with a concomitant risk of a significant under-estimation of the true mortality rate of EDs.
(I propose to explore this issue in separate correspondence with the Medical Examiner for England and Wales (copied in to this Report), the Office for National Statistics and the Coroners’ Society of England and Wales).
In my view, taken together, the absence of statistically robust data on the numbers of those suffering from EDs and the potential under-estimation of those deaths to which EDs may have caused or contributed, gives rise to an objective risk that avoidable ED deaths will continue in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of robust and reliable prevalence data for eating disorders
Wider context from the report “(3) Lack of robust and reliable data regarding the prevalence of eating disorders
Evidence also confirmed that the lack of precise information on the prevalence of eating disorders in the United Kingdom , described by the PHSO Report and the PACAC Follow-up Report as “shocking, given the claim that up to 1.25 million people are suffering from an eating disorder and the fact that eating disorders have the highest mortality rate of mental illnesses” persists. The witness evidence also confirmed the view expressed in the PACAC Report. “This vagueness limits the ability of NHS commissioners to gauge what services need to be provided and encourages them to devote resources to better recorded diseases.”
Further, I am concerned that there may also be a significant under-reporting of the extent to which EDs have caused or contributed to deaths, leading to cases either not being referred to the coroner or, if they are, the coroner in question determining that death was one of ‘natural causes’, with only the terminal cause of death, and not the underlying ED cause or contribution to the death, being recorded. In such circumstances there is a concern that a number of such deaths (where, for example, lack of care may have contributed to the death) are neither investigated appropriately by the coroner nor taken to inquest with a concomitant risk of a significant under-estimation of the true mortality rate of EDs.
(I propose to explore this issue in separate correspondence with the Medical Examiner for England and Wales (copied in to this Report), the Office for National Statistics and the Coroners’ Society of England and Wales).
In my view, taken together, the absence of statistically robust data on the numbers of those suffering from EDs and the potential under-estimation of those deaths to which EDs may have caused or contributed, gives rise to an objective risk that avoidable ED deaths will continue in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Shortage of eating disorder specialists
Wider context from the report “(1) Inadequate training of doctors and other medical professionals re eating disorders
Evidence from a wide range of clinicians who had engaged with Averil in 2012 echoed the evidence of clinicians attending the four inquests of the women referred to above. All five inquests revealed a common theme of wide-spread and continuing lack of training, knowledge, or experience on the part of physicians and medical staff (including GPs and nurse practitioners, as well as acute hospital doctors, nurses and dieticians) regarding eating disorders (EDs) and specifically Anorexia Nervosa (AN). Many witnesses (from both the death 2012 and those in 2017/2018) conceded that they had only the most superficial knowledge of the often complex issues relating to recognition, monitoring, management and treatment of EDs and AN specifically. Their evidence often reflected a lack of familiarity with the King’s College Guidance for the treatment of AN in the community. The evidence of hospital staff revealed, at best, inconsistent implementation of the Royal College of Psychiatrists MARSIPAN guidance for the emergency treatment of AN patients and, at worst, a failure to implement the Guidance at all.
Evidence at Averil’s inquest (and at those of ████████) suggested that limited progress has been made in respect of the PHSO recommendation with regard to the training of doctors and other medical professionals, (notwithstanding the further recommendations of the PACAC Follow-up Report and the Government Response to the latter’s Recommendations). These concerns have been reiterated by the Position Statement of the Royal College of Psychiatrists (PS04/20) of September 2020 “Improving core skills and competence in risk assessment and management of people with eating disorders: What all doctors need to know.”
The evidence at inquest of senior practitioners in the fields of psychiatry, psychology, acute medicine, dietetics, gastroenterology and GP practice all confirmed that there remains, as there was in 2012, a continuing and serious shortage of eating disorder specialists across the country with many Trusts finding it difficult to fill vacancies ; such shortages inevitably impact upon the level and quality of support available to primary care providers and other specialists and therefore, in my view, risks avoidable future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of formally commissioned monitoring provision for moderate to high risk Anorexia Nervosa patients
Wider context from the report “(2) Lack of formally commissioned service level agreement for the provision of robust and effective monitoring of moderate to high risk AN patients by primary or secondary care providers
Evidence confirmed that in response to the PHSO Report an Expert Reference Group (ERG) was convened by NHS England (NHSE) to address the specific recommendation for NHSE to review the existing quality and availability of services to achieve parity for adult ED services with children and young people’s ED services. The National Collaborating Centre for Mental Health (NCCMH) was commissioned to develop new guidance published in August 2019: “Adult Eating Disorders: Community, Inpatient and Intensive Day Patient Care – Guidance for Commissioners and Providers”.
However, the clear and unchallenged evidence received at Averil’s inquest confirmed that there remains a lack of formally commissioned provision for the monitoring of AN patients in primary or secondary care across large parts of the United Kingdom . Whilst the evidence received indicated that Cambridgeshire & Peterborough NHS Foundation Trust are seeking to develop models to ensure the provision of medical monitoring for all ED sufferers, including moderate to high risk patients, there are many areas in the country – including parts of the East of England Region – which still have no such formally commissioned provision. Further, unchallenged evidence identified a number of regions as not even having consultant level psychiatric in-put to the ED services that are purportedly available.
There was unanimity on the part of each of the senior clinicians who gave evidence, as well as a number of independent, instructed experts in the fields of ED and AN, that the continued absence of such monitoring and treatment provision gave rise to not only the risk of avoidable future deaths, but - in the views of many - the inevitability of the same. Evidence confirmed that whilst AN has the highest mortality of any mental disorder affecting young people and adults this should not be simply accepted and that AN and other EDs are treatable mental disorders, with even severe complications such as malnutrition safely reversible. The evidence further established that whilst in the long term primary prevention strategies including early recognition and treatment of the disease was critical, in the short to medium term, improving access to treatment and the effective monitoring of the severely ill is to be regarded as essential to address the risk of avoidable future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation COVID-19 pandemic exacerbation of eating disorder safety deficiencies
Wider context from the report “(4) The impact of the COVID 19 pandemic
I am concerned that the matters giving rise to the risk of future deaths identified at points (1) to (3) above have been - and will continue to be - significantly exacerbated by the on-going pandemic . I therefore request that responses to the above recognise and expressly address this concern.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Allocate £58 million to accelerate integrated primary and secondary community support for adults with severe mental illness, including eating disorders.
Verbatim wording from the response “As part of the Government’s commitment to build back better post-COVID, on 27 March we published our Mental Health Recovery Action Plan⁴, backed by an additional £500 million of targeted investment, to ensure that we have the right support in place over the coming year.” Source location 2021-0058-Response-from-Department-of-Health-Social-Care-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand and transform mental health services in England, supported by additional annual investment by 2023/24.
Verbatim wording from the response “Under the NHS Long Term Plan, we are committed to ensuring a more integrated service across primary and secondary care for people with severe mental illnesses, including eating disorders, and to giving 370,000 adults with severe mental illness greater choice and control over their care and support to live well in their communities by 2023/24. To support improvements in mental health care more generally, including eating disorder care, we remain committed to expanding and transforming mental health services in England and to investing an additional £2.3 billion a year in mental health services by 2023/24.” Source location 2021-0058-Response-from-Department-of-Health-Social-Care-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a more integrated primary and secondary care service for people with severe mental illnesses, including eating disorders.
Verbatim wording from the response “Under the NHS Long Term Plan, we are committed to ensuring a more integrated service across primary and secondary care for people with severe mental illnesses, including eating disorders, and to giving 370,000 adults with severe mental illness greater choice and control over their care and support to live well in their communities by 2023/24. To support improvements in mental health care more generally, including eating disorder care, we remain committed to expanding and transforming mental health services in England and to investing an additional £2.3 billion a year in mental health services by 2023/24.” Source location 2021-0058-Response-from-Department-of-Health-Social-Care-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for addressing the shortage of eating disorder specialists rests with the GMC, HEE and the Academy of Medical Royal Colleges.
Verbatim wording from the response “In relation to the training of medical professionals in eating disorders, we agree that doctors should have the necessary knowledge and experience to assess patients holistically, considering the individuals’ physical, social and psychological needs. Through the PHSO delivery group, NHSEI is working with HEE and other partners to procure training courses that will increase the capacity of the existing workforce to allow them to provide evidence-based treatment to more people, as they have set out in detail in their responses. I share your concerns on the shortage of eating disorder specialists across the country. I understand that colleagues in the GMC, HEE and the Academy of Medical Royal Colleges will also address this in their responses.” Source location 2021-0058-Response-from-Department-of-Health-Social-Care-Redacted
Open published response
3 Mar 2021 Steven Paul David Gary Stout · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Failure to ensure effective referral from the ward to the community home treatment team View source Failure to accurately record and file important medical records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Steven Paul David Gary Stout · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Steven Paul David Gary Stout was detained under section 136 of the Mental Health Act after cutting both wrists while intoxicated by alcohol, and was later admitted to a mental health ward. He was discharged on 18 October 2019 without a referral to the home treatment team and was found unresponsive, suspended by his neck from a ligature, on 4 November 2019; he could not be resuscitated. The concerns included failures to accurately record and file important medical records and to ensure an effective referral to the home treatment team.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure effective referral from the ward to the community home treatment team
Wider context from the report “2. The failure of Turner Ward Goodmayes hospital to ensure the effective referral of a patient from the ward to the home treatment team within the community .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record and file important medical records
Wider context from the report “1. The failure of Turner Ward, Goodmayes hospital to accurately record and file important medical records including; decisions on discharge, risk assessments, and a crisis, relapse and contingency plan .
” Open source report
19 Feb 2021 Ms Lisa Grant · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 1 Significantly increased risk of deep vein thrombosis associated with obesity, inactivity and a rare recognised Risperidone side effect View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ms Lisa Grant · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ms Lisa Grant was admitted to Hallam Street Hospital in July 2019 and collapsed on the ward on 1 August 2019, later dying at Sandwell Hospital. The inquest identified bilateral pulmonary embolism due to deep vein thrombosis, and concerns included her increased DVT risk associated with obesity and inactivity, alongside a recognised rare risk associated with risperidone, despite an assessment that no further DVT treatment or assessment was required.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Significantly increased risk of deep vein thrombosis associated with obesity, inactivity and a rare recognised Risperidone side effect
Wider context from the report “1. Evidence emerged during the inquest that both the consulting Psychiatrist and the Hospital’s Manager said that Ms Grant was assessed upon admission to hospital in accordance with the national guidelines for the assessment for Deep vein thrombosis (DVT). As per the guidance criteria checklist, the clinician considered that there was no significant reduction in mobility, and therefore no further treatment or assessment for this condition was required.
2. Miss Grant had a significantly increased risk of DVT due to the effects of obesity and inactivity. In addition, there was a rare but recognised side effect of Risperidone.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NICE will consider whether specific VTE risk-assessment tools are needed for acute psychiatric patients at its next guideline review.
Verbatim wording from the response “The Guideline references a tool commonly used in the NHS for hospital patients: the Department of Health risk assessment for VTE (see recommendation 1.9.1). NICE notes in the Guideline that the tool has not been validated or tested against other tools to evaluate its diagnostic accuracy or effectiveness at correctly identifying people at risk of VTE. The NICE guideline committee made a research recommendation in this area, reflecting the uncertainty in the evidence for one risk tool over another.” Source location 2021-0073-Response-from-Department-of-Health-and-Social-Care_Published
Open published response
Concerns raised 3 Failure of doctors considering opiate prescriptions to contact the registered GP View source Lack of an effective national procedure for circulating Patient Alerts to pharmacies View source Failure of dispensing pharmacists to contact the registered GP when checking prescription appropriateness View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Katie Emma Corrigan · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Katie Emma Corrigan had a history of chronic pain, anxiety and depression, and developed an addiction to pain-relieving medication. She obtained medication from multiple sources, and the report raised concerns that doctors, pharmacists and alert systems did not prevent her from obtaining sufficient opiate medication to cause her death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of doctors considering opiate prescriptions to contact the registered GP
Wider context from the report “The GP who gave evidence at the inquest, Dr ████████ from Bodriggy Health Centre in Hayle, stated that she had never been contacted by any other doctor considering the prescription of opiate or other medication to Mrs Corrigan . She was able to procure the medication in sufficient quantities first to require an emergency admission to hospital and latterly to result in her death.
Similarly, the registered GP was not contacted by any dispensing pharmacist checking whether the prescription was appropriate.
After Dr ████████ became aware of the two on-line pharmacies who had dispensed the medication to Mrs Corrigan that led to her admission into hospital, she attempted to raise an alert through NHS England, in order that the unsuitability of prescribing opiate medication to Mrs Corrigan could be raised with clinicians. This was sent out regionally but Dr ████████ has since been advised there is no formal procedure for circulating Patient Alerts to pharmacies on a national level.
I am further given to understand that non NHS contacts would only receive a redacted version of the alert in any event.
What seems clear is that the alert proved ineffective in preventing Mrs Corrigan from improperly obtaining sufficient quantities of opiate medication to result in her death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective national procedure for circulating Patient Alerts to pharmacies
Wider context from the report “The GP who gave evidence at the inquest, Dr ████████ from Bodriggy Health Centre in Hayle, stated that she had never been contacted by any other doctor considering the prescription of opiate or other medication to Mrs Corrigan. She was able to procure the medication in sufficient quantities first to require an emergency admission to hospital and latterly to result in her death.
Similarly, the registered GP was not contacted by any dispensing pharmacist checking whether the prescription was appropriate.
After Dr ████████ became aware of the two on-line pharmacies who had dispensed the medication to Mrs Corrigan that led to her admission into hospital, she attempted to raise an alert through NHS England, in order that the unsuitability of prescribing opiate medication to Mrs Corrigan could be raised with clinicians. This was sent out regionally but Dr ████████ has since been advised there is no formal procedure for circulating Patient Alerts to pharmacies on a national level .
I am further given to understand that non NHS contacts would only receive a redacted version of the alert in any event .
What seems clear is that the alert proved ineffective in preventing Mrs Corrigan from improperly obtaining sufficient quantities of opiate medication to result in her death .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of dispensing pharmacists to contact the registered GP when checking prescription appropriateness
Wider context from the report “The GP who gave evidence at the inquest, Dr ████████ from Bodriggy Health Centre in Hayle, stated that she had never been contacted by any other doctor considering the prescription of opiate or other medication to Mrs Corrigan. She was able to procure the medication in sufficient quantities first to require an emergency admission to hospital and latterly to result in her death.
Similarly, the registered GP was not contacted by any dispensing pharmacist checking whether the prescription was appropriate .
After Dr ████████ became aware of the two on-line pharmacies who had dispensed the medication to Mrs Corrigan that led to her admission into hospital, she attempted to raise an alert through NHS England, in order that the unsuitability of prescribing opiate medication to Mrs Corrigan could be raised with clinicians. This was sent out regionally but Dr ████████ has since been advised there is no formal procedure for circulating Patient Alerts to pharmacies on a national level.
I am further given to understand that non NHS contacts would only receive a redacted version of the alert in any event.
What seems clear is that the alert proved ineffective in preventing Mrs Corrigan from improperly obtaining sufficient quantities of opiate medication to result in her death.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHSEI is responsible for systems oversight of controlled-drug management and use, including the alert system’s operation.
Verbatim wording from the response “In relation to the effectiveness of NHS England and NHS Improvement’s (NHSEI’s) alert system in preventing people from obtaining prescription-only medicines improperly, my officials have brought your concerns to the attention of NHSEI.” Source location 2021-0045-Response-from-Dept-of-Health-and-Social-Care-Redacted
Open published response
11 Feb 2021 Ruth Jones · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Lack of guidance for managing falls risk during resident isolation View source Failure to support effective communication and understanding of the health baseline of vulnerable frail elderly patients during hospital presentation and assessment View source Insufficient staffing capacity for continuous observation of residents at risk of falls during self-isolation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ruth Jones · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ruth Jones, a resident of The Beeches Care Home who was at risk of falls, fell while unobserved after being isolated because Covid-19 was suspected. She was admitted to hospital with a fractured neck of femur and bronchopneumonia and later died there. Concerns included the lack of guidance and staffing arrangements for safely observing residents at risk of falls during required isolation, and the difficulties caused when frail patients attended hospital without family support.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for managing falls risk during resident isolation
Wider context from the report “1. The inquest heard that Mrs Jones was frail and at risk of falls. The home had a falls risk plan in place that was based around her being observed during the day in communal areas. The home was not staffed to provide one to one observations for residents required to self-isolate. As a result when Covid 19 was suspected by the GP, and the home were directed to isolate her she could not be observed by staff as would generally be the case in the day. The home took some steps with sensors to ensure they were aware if she stood up whilst in her room but could not provide continuous observation. It was unclear how homes were being advised to safely manage residents at risk of falls where isolation was required . The home were unaware of any guidance that they should follow to manage the risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to support effective communication and understanding of the health baseline of vulnerable frail elderly patients during hospital presentation and assessment
Wider context from the report “2. When Mrs Jones had to go to hospital she was sent alone and her family could not go with her due to Covid 19 restrictions. The inquest heard that Mrs Jones was frail and vulnerable. The inquest was told that the unsupported presentation/assessment of vulnerable, frail and elderly patients such as Mrs Jones presented significant problems to clinicians in terms of effective communication and understanding their health baseline to support appropriate and timely clinical decision making.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing capacity for continuous observation of residents at risk of falls during self-isolation
Wider context from the report “1. The inquest heard that Mrs Jones was frail and at risk of falls. The home had a falls risk plan in place that was based around her being observed during the day in communal areas. The home was not staffed to provide one to one observations for residents required to self-isolate . As a result when Covid 19 was suspected by the GP, and the home were directed to isolate her she could not be observed by staff as would generally be the case in the day . The home took some steps with sensors to ensure they were aware if she stood up whilst in her room but could not provide continuous observation . It was unclear how homes were being advised to safely manage residents at risk of falls where isolation was required. The home were unaware of any guidance that they should follow to manage the risk.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Highlight links to RESTORE2 and British Geriatrics Society guidance more explicitly in care-home admissions guidance.
Verbatim wording from the response “You may also wish to note that guidance in April 2020, Coronavirus (COVID-19): admissions and care of people in care homes², contained a link to RESTORE2³, a physical deterioration and escalation tool for care and nursing homes, as well as guidance on managing COVID-19 and care homes, published by the British Geriatrics Society⁴. These sources provide clear guidance on the importance of providing a concise escalation history to health professionals to support their professional decision making, and advance care planning. Reference is also made in the guidance to Enhanced Health in Care Homes⁵, a new, proactive model of care, centred on the needs of the individual.” Source location 2021-0038-Response-from-Dept.-of-Health-Social-Care-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include a link to Falls and Fractures guidance in the care-home admissions guidance.
Verbatim wording from the response “Extensive guidance is available on best practice on safely managing residents at risk of falls. Specifically, the guidance, Falls and Fractures: applying All Our Health⁷ (which includes links to NICE standards), should continue to be followed at all times, including during the COVID-19 outbreak. This guidance was last updated in January 2020.” Source location 2021-0038-Response-from-Dept.-of-Health-Social-Care-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Seek clarification from Public Health England and NHS England and NHS Improvement on adjustments needed to Falls and Fractures guidance for self-isolating care-home residents.
Verbatim wording from the response “Extensive guidance is available on best practice on safely managing residents at risk of falls. Specifically, the guidance, Falls and Fractures: applying All Our Health⁷ (which includes links to NICE standards), should continue to be followed at all times, including during the COVID-19 outbreak. This guidance was last updated in January 2020.” Source location 2021-0038-Response-from-Dept.-of-Health-Social-Care-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Care homes are statutorily responsible for assessing and mitigating residents’ health and safety risks, including risks associated with falls.
Verbatim wording from the response “Under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014⁶, care homes have a statutory duty to ensure safe care and treatment for service users. This includes assessing the risks to the health and the safety of service users in a manner that is reasonably practicable to mitigate any such risks.” Source location 2021-0038-Response-from-Dept.-of-Health-Social-Care-Redacted
Open published response
11 Feb 2021 Carole Mitchell · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Insufficient local mental health inpatient bed capacity View source Delays in access to psychology assessment and therapies View source Failure to fully utilise information gathering from family due to misunderstanding of confidentiality View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Carole Mitchell · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Carole Mitchell died at home on 22 November 2019 after taking a fatal amount of her prescribed medication; the inquest conclusion was suicide. The report identifies concerns about delays in accessing psychological assessment and support-worker services, limited mental health bed capacity, and difficulties gathering information from her family because of concerns about confidentiality.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient local mental health inpatient bed capacity
Wider context from the report “2. Mrs Mitchell on two occasions could not be accommodated locally when an inpatient stay was required . The evidence heard at the inquest was that this was due to limited national mental health bed capacity against the demand within mental health services . The inquest heard evidence that suggested that this impacted on how she could be supported by her family and overall care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in access to psychology assessment and therapies
Wider context from the report “1. The inquest heard that psychology assessment and therapies can be very beneficial to those with mental health issues in secondary services as well as primary services. The evidence given was that the delay that Mrs Mitchell experienced in accessing that service was reflective of both the regional and national backlog for appointments . The inquest was told that the position had worsened since 2019 and for example someone in Mrs Mitchell’s position today would be more likely to wait 9 months than the 7 months in 2019 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to fully utilise information gathering from family due to misunderstanding of confidentiality
Wider context from the report “3. It was accepted at the inquest that information gathering from family could be beneficial. However, there was a reluctance by health professionals to fully utilise information gathering due to concerns about breaching patient confidentiality . This appeared to stem from a misunderstanding between the concept of information sharing and information gathering and how they inter related with the principle of patient confidentiality .
” Open source report
2 Feb 2021 Cyril Cheetham · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Additional telephone triage causing delays in admission for elderly patients View source Lack of adequate audit of the Alternative to Transfer service’s net benefit and adverse outcomes View source Lack of clarity in Alternative to Transfer eligibility and responsibility criteria View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Cyril Cheetham · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Cyril Cheetham, aged 91 and resident in a care home, became unwell on 20.02.19, was admitted to hospital later that day, placed on an end-of-life pathway, and died on 25.02.19. The principal concern was that unclear responsibility between Mastercall and his own GP resulted in no same-day GP attendance, alongside concerns that the ATT service lacked adequate auditing and that its triage arrangements could delay hospital admission and contribute to future deaths.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Additional telephone triage causing delays in admission for elderly patients
Wider context from the report “The ATT services introduces an additional layer of triage based on a telephone conversation between a clinician at Mastercall and someone at the care home, who may be a carer or a nurse, and may be experienced or inexperienced, rather than that person calling 999. It is of concern to me that this additional layer may result in a delay in admission, which for an elderly patient with likely co-morbidities, will affect their prospects.
It was accepted that there was no audit or research carried out in respect of any deaths arising from delay in admission where the ATT service was used. The net benefit seems to have been calculated by reference to resource savings alone.
I am concerned that the ATT service is being resourced and provided (nationally) without any adequate or true audit of its perceived net benefit, and that its use may be costing lives, either at all or at an unacceptable level.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate audit of the Alternative to Transfer service’s net benefit and adverse outcomes
Wider context from the report “The ATT services introduces an additional layer of triage based on a telephone conversation between a clinician at Mastercall and someone at the care home, who may be a carer or a nurse, and may be experienced or inexperienced, rather than that person calling 999. It is of concern to me that this additional layer may result in a delay in admission, which for an elderly patient with likely co-morbidities, will affect their prospects.
It was accepted that there was no audit or research carried out in respect of any deaths arising from delay in admission where the ATT service was used. The net benefit seems to have been calculated by reference to resource savings alone.
I am concerned that the ATT service is being resourced and provided (nationally) without any adequate or true audit of its perceived net benefit , and that its use may be costing lives, either at all or at an unacceptable level.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in Alternative to Transfer eligibility and responsibility criteria
Wider context from the report “Issue Two
The inquest highlighted a lack of clarity as to the criteria for the ATT service.
The conversation between Mastercall and the own GP highlighted the ‘grey area’ that exists between a routine (no risk of admission) attendance and a ‘risk of admission’ attendance. It is clear from the events that unfolded that Mr Cheetham clearly was at risk of admission. In my view the lack of clarity resulted in Mr Cheetham not being seen by a GP that afternoon while there was likely no difference in outcome in his case, it is clear that this existence of a ‘grey area’ of responsibility might result in future deaths.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a full audit of the Alternative to Transfer service to assess whether it delivers safe, high-quality patient care.
Verbatim wording from the response “Nevertheless, I am pleased to be informed that Mastercall has undertaken to conduct a full audit of the ATT service to ensure it is delivering high-quality, safe services to patients. In” Source location 2021-0022-Response-from-Dept-of-Health-and-Social-Care-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review all calls to the Alternative to Transfer service to provide immediate assurance about service safety.
Verbatim wording from the response “addition, to provide more immediate assurance, all calls to the ATT service are being reviewed.” Source location 2021-0022-Response-from-Dept-of-Health-and-Social-Care-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clinical commissioning groups are responsible for planning, commissioning, monitoring and assuring local out-of-hours health services.
Verbatim wording from the response “It may be helpful if I begin by explaining that the planning and commissioning of local health services in England is the responsibility of clinical commissioning groups (CCGs), which have the knowledge of their local population healthcare needs and can design services to meet those needs. This includes out-of-hours services. It is the responsibility of CCGs to monitor and assure the delivery of services in line with agreed service specifications.” Source location 2021-0022-Response-from-Dept-of-Health-and-Social-Care-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing contract monitoring, eligibility guidance and senior-clinician triage were considered adequate, with no significant concerns identified.
Verbatim wording from the response “I am advised that the Stockport CCG has provided a response to you explaining the regular contract monitoring that is in place with Mastercall, the provider of the ‘Alternative to Transfer’ (ATT) service, and confirming that no significant concerns have been identified by the CCG. I am further advised that clear guidance is in place in relation to the patients that meet the criteria for the service and that calls to the service are triaged by senior clinicians.” Source location 2021-0022-Response-from-Dept-of-Health-and-Social-Care-Redacted
Open published response
27 Jan 2021 Michael Chahwanda · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 3 Lack of specific postnatal Vitamin D supplementation advice for attending Health Visitors View source Lack of directive for women at increased risk to take Vitamin D supplements View source Lack of Vitamin D provision to women and babies at increased risk of deficiency View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Michael Chahwanda · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Chahwanda was born on 19 September 2018 and died at Royal Manchester Children’s Hospital on 16 December 2018 after suffering a seizure at home. The report states that his death was associated with severe Vitamin D deficiency, with circulatory failure following an out-of-hospital cardiac arrest and cardiomyopathy associated with Vitamin D deficiency recorded at inquest. Concerns included the lack of specific postnatal Vitamin D supplementation advice in the Red Book and the absence of a directive for, or provision of supplements to, women and breast-fed babies at increased risk of deficiency.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of specific postnatal Vitamin D supplementation advice for attending Health Visitors
Wider context from the report “1. To The Royal College of Paediatrics and Child Health and Department of Health and Social Care and The National Institute for Health and Care Excellence: To consider an amendment to the Red Book to include specific advice for Vitamin D supplementation in the postnatal period to be given by the attending Health Visitor . Such advice would be consistent with national guidance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of directive for women at increased risk to take Vitamin D supplements
Wider context from the report “2. To Department of Health and Social Care and The National Institute for Health and Care Excellence : To consider an amendment to the guidelines so that there is a directive for women (particularly those with an increased skin pigmentation and those who are breast-feeding) to take Vitamin D supplements . Also, to consider the provision of Vitamin D to women and babies who are at an increased risk of Vitamin D deficiency.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of Vitamin D provision to women and babies at increased risk of deficiency
Wider context from the report “2. To Department of Health and Social Care and The National Institute for Health and Care Excellence : To consider an amendment to the guidelines so that there is a directive for women (particularly those with an increased skin pigmentation and those who are breast-feeding) to take Vitamin D supplements. Also, to consider the provision of Vitamin D to women and babies who are at an increased risk of Vitamin D deficiency .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide targeted vitamin D advice and free supplements to eligible women, babies and young children at increased risk of deficiency.
Verbatim wording from the response “In line with advice from the Scientific Advisory Group, the Department has put in place measures to provide vitamin D supplements to women and babies who are at increased risk. Through universal health and wellbeing reviews offered to new parents, health visitors provide targeted advice to parents on vitamin drops and where to get them. Pregnant women, new mothers and children under the age of four who are on low incomes and in receipt of defined social security benefits are entitled to free vitamin D supplements through the Healthy Start scheme. Healthy Start Vitamins for women and children contain a daily dose of 10 microgrammes of vitamin D. Under current advice from the Scientific Advisory Group, the Department does not plan to change current policy on the guidance and provision of vitamin D.” Source location 2021-0020-Response-from-Dept-of-Health-and-Social-Care-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review NHS.UK and Start4Life vitamin D references to clarify requirements for pregnant and breastfeeding women and infants, particularly those with dark skin.
Verbatim wording from the response “However, we appreciate that more can always be done, and we will review all NHS.UK and Start4Life references to vitamin D to ensure that the requirements for pregnant and breast-feeding women and their infants, particularly those with dark skin, are absolutely clear. I will discuss with my fellow Minister, Nadine Dorries, the importance of it being talked about between the midwife and mother.” Source location 2021-0020-Response-from-Dept-of-Health-and-Social-Care-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Current advice and provision measures are sufficient; no change to vitamin D guidance or provision is planned.
Verbatim wording from the response “In relation to the provision of vitamin D supplements to specific population groups at increased risk from vitamin D deficiency, the Scientific Advisory Committee on Nutrition is responsible for advising the Government on the vitamin D needs of the population.” Source location 2021-0020-Response-from-Dept-of-Health-and-Social-Care-Redacted
Open published response
19 Jan 2021 Vhari Ingall · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 5 Unavailability of a centralised or regionalised database for emergency access to TEP/DNAR information View source Failure to ensure treatment-withdrawal decisions are not made by frontline paramedics View source Failure to ensure accurate and checkable TEP/DNAR information for emergency decision-making View source Failure to review TEP/DNAR documents when clinically significant diagnostic information changes View source Failure to limit Do Not Resuscitate document applicability to natural deaths View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Vhari Ingall · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Vhari Ingall died from an oxycodone drug overdose, with the inquest returning a conclusion of suicide. The principal concerns were the failure to review an outdated Treatment Escalation Plan/Do Not Resuscitate form after her diagnosis changed, and whether healthcare professionals and emergency services could access accurate and current information about such forms.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a centralised or regionalised database for emergency access to TEP/DNAR information
Wider context from the report “The Paramedics in both of these cases were faced with extremely difficult situations and on the front line are having to make very difficult decisions and need to rely on the best available information which needs to be accurate. In Vhari’s case, Vhari herself was able to explain that the diagnosis of the pancreatic tumour was incorrect but that may not always be the case in every similar situation and in fact when the paramedics attended Mrs. Johnson she presented initially with a Glasgow coma scale of 7 and was not really responsive at any time when the paramedics were present.
I would be grateful if you would please consider as part of your inspection methodology including looking at the system in place for the management of TEP/DNARs, as my concern is that with inaccurate information and the inability to check that information that potentially decisions could be made that perhaps would not be made leading to allowing somebody to die that was based on inaccurate information.
B) DEPARTMENT OF HEALTH
Leading on from the above section addressed to the Care Quality Commission, whilst present practice places an obligation on the patient to have available the TEP/DNAR, even to the extent that I believe there is a practice of advising that a copy be left in the fridge/freezer at the patient’s home. ████████ himself did not have a copy of the TEP/DNAR which he signed on his case records at the surgery on the basis that he said that the original is left with the patient. I did express some surprise about that as to why at least a photograph of the document could not have been taken and transferred on to the case records, the original photograph then deleted from whatever device took it. As an alternative so that any health care professional can access the best available information as regards the existence of a TEP/DNAR, especially when the patient may not be able to assist at the scene and may not have told a relative of friend of its existence, I do question why there is not some central database or even as an alternative a regionalised database that could be accessed by the emergency services including health care practitioners . These are important documents and it may be the case that the individual concerned does not have a friend or relative that they can make aware of the existence of such a document and may be truly alone and unresponsive at the time the emergency services attend.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure treatment-withdrawal decisions are not made by frontline paramedics
Wider context from the report “Even though neither of these cases have proceeded to a final Inquest hearing in accordance with Regulation 28 of the Coroners (Investigation) Regulation 2013 a report to prevent future deaths can be made if evidence comes before the Coroner that causes a concern and triggers the Coroner’s duty to submit such a report if the Coroner thinks it is appropriate. I am of the view that this duty has now been triggered because the death of Ms. Ingall raises the same issue and concern that I have following the death of Mrs. Johnson. The concern is that the Do Not Resuscitate document applies to all my sociality a natural death. We know that Mrs. Johnson did not die a natural cause of death and there were sufficient information indicators at the scene and the Paramedics were aware that she had taken, more likely than not, an overdose. The same appears to be the case with Ms. Ingall although this is subject to confirmation following the post mortem examination. A person dying as a result of self-harm and as a result of an overdose cannot if any way whatsoever be regarded as a natural death, it is my view and concern that Paramedics are being placed in a difficult position as well of those that they are responsible for caring for if they do not intervene appropriately. It may be the case at hospital and potentially with the involvement of mental health professionals that a decision is taken to withdraw treatment, but I am concerned, especially having regard to Article 2 of the European Convention of Human Rights that that decision is not taken by frontline Paramedics and I would ask you to urgently review the instructions and guidance given to your frontline Paramedics in these situations .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accurate and checkable TEP/DNAR information for emergency decision-making
Wider context from the report “The Paramedics in both of these cases were faced with extremely difficult situations and on the front line are having to make very difficult decisions and need to rely on the best available information which needs to be accurate . In Vhari’s case, Vhari herself was able to explain that the diagnosis of the pancreatic tumour was incorrect but that may not always be the case in every similar situation and in fact when the paramedics attended Mrs. Johnson she presented initially with a Glasgow coma scale of 7 and was not really responsive at any time when the paramedics were present.
I would be grateful if you would please consider as part of your inspection methodology including looking at the system in place for the management of TEP/DNARs, as my concern is that with inaccurate information and the inability to check that information that potentially decisions could be made that perhaps would not be made leading to allowing somebody to die that was based on inaccurate information .
B) DEPARTMENT OF HEALTH
Leading on from the above section addressed to the Care Quality Commission, whilst present practice places an obligation on the patient to have available the TEP/DNAR, even to the extent that I believe there is a practice of advising that a copy be left in the fridge/freezer at the patient’s home. ████████ himself did not have a copy of the TEP/DNAR which he signed on his case records at the surgery on the basis that he said that the original is left with the patient. I did express some surprise about that as to why at least a photograph of the document could not have been taken and transferred on to the case records, the original photograph then deleted from whatever device took it. As an alternative so that any health care professional can access the best available information as regards the existence of a TEP/DNAR, especially when the patient may not be able to assist at the scene and may not have told a relative of friend of its existence, I do question why there is not some central database or even as an alternative a regionalised database that could be accessed by the emergency services including health care practitioners. These are important documents and it may be the case that the individual concerned does not have a friend or relative that they can make aware of the existence of such a document and may be truly alone and unresponsive at the time the emergency services attend.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to review TEP/DNAR documents when clinically significant diagnostic information changes
Wider context from the report “During the Inquest into the death of Vhari I heard evidence from the Senior Partner of her GP surgery, New Court Surgery at Royal Wootton Bassett, Wiltshire as I had a concern in relation to the Treatment Escalation Plan/Do Not Resuscitation (“TEP/DNAR”) form which ████████ had completed with Vhari back in February 2017. I have enclosed a copy of that TEP/DNAR marked “A”. As you will see the reason for issuing it was that Vhari had been diagnosed, late during the previous year, with a pancreatic tumour and she was considered for palliative care only. Towards the end of 2017, the Consultant at Great Western Hospital in charge of her care, reviewed Vhari’s case and the diagnosis changed to one of chronic pancreatitis as opposed to a terminal tumour. This was confirmed in writing to the surgery on the 17 September 2017. During the course of ████████ evidence he explained to me the quite sensible reason why there is no fixed date review of these types of documents but did indicate that such a review was entirely appropriate when it was clinically appropriate to review the TEP/DNAR document. I was firmly of the view that a change in such a fundamental diagnosis should have ordinarily given rise to a review , however, I found no evidence that was recorded in Vhari’s case to suggest that such a review was undertaken by the surgery even though there was a number of consultations with different doctors following Mr. Payne’s letter of September 2017. The notes were completely silent as regards any such review being carried out . In fact I noted an entry in the records on the 5 March 2020 by one of the doctors at the surgery, ████████ who referred to “reminder/alert: DNAR-priority: high.” I also heard evidence from Vhari’s sister, ████████ that in going through Vhari personal possession she found no subsequent TEP/DNAR form after the February 2017 form.
I did consider sending a Regulation 28 Report to the surgery but heard evidence from ████████ that they now have provided by the local CCG an add on to their SystemOne system called an Arden’s module which assists in clinical decision making which they are also using in relation to recording TEP/DNARs. Whilst there is never a 100% guarantee that such a failure to review a document like this will not occur in the future and in respect of Vhari’s case it was in no way contributory to her death, I was satisfied that this step was an improvement and an attempt to mitigate against the risk of such a recurrence.
Obviously, this package is available to surgeries within my own coronial area, but I am unclear as to the position in other areas and obviously you have a greater awareness of these sorts of matters as part of your inspection processes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to limit Do Not Resuscitate document applicability to natural deaths
Wider context from the report “Even though neither of these cases have proceeded to a final Inquest hearing in accordance with Regulation 28 of the Coroners (Investigation) Regulation 2013 a report to prevent future deaths can be made if evidence comes before the Coroner that causes a concern and triggers the Coroner’s duty to submit such a report if the Coroner thinks it is appropriate. I am of the view that this duty has now been triggered because the death of Ms. Ingall raises the same issue and concern that I have following the death of Mrs. Johnson. The concern is that the Do Not Resuscitate document applies to all my sociality a natural death. We know that Mrs. Johnson did not die a natural cause of death and there were sufficient information indicators at the scene and the Paramedics were aware that she had taken, more likely than not, an overdose. The same appears to be the case with Ms. Ingall although this is subject to confirmation following the post mortem examination. A person dying as a result of self-harm and as a result of an overdose cannot if any way whatsoever be regarded as a natural death , it is my view and concern that Paramedics are being placed in a difficult position as well of those that they are responsible for caring for if they do not intervene appropriately. It may be the case at hospital and potentially with the involvement of mental health professionals that a decision is taken to withdraw treatment, but I am concerned, especially having regard to Article 2 of the European Convention of Human Rights that that decision is not taken by frontline Paramedics and I would ask you to urgently review the instructions and guidance given to your frontline Paramedics in these situations.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission a review of pandemic-era DNACPR use to identify recommendations preventing inappropriate notices on patient records.
Verbatim wording from the response “In light of concerns around DNACPR notices used during the pandemic, the Department commissioned the Care Quality Commission to review the use of DNACPRs and provide a series of recommendations to ensure inappropriate notices are not placed on patient’s records. The final report was published on 18 March 2021. We are committed to driving forward implementation of the recommendations within the report.” Source location 2020-0084-Response-from-Dept-of-Health-and-Social-Care-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Drive forward implementation of the Care Quality Commission’s recommendations on pandemic-era DNACPR use.
Verbatim wording from the response “In light of concerns around DNACPR notices used during the pandemic, the Department commissioned the Care Quality Commission to review the use of DNACPRs and provide a series of recommendations to ensure inappropriate notices are not placed on patient’s records. The final report was published on 18 March 2021. We are committed to driving forward implementation of the recommendations within the report.” Source location 2020-0084-Response-from-Dept-of-Health-and-Social-Care-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The healthcare professionals responsible for immediate care retain the final decision on whether attempting CPR is clinically appropriate.
Verbatim wording from the response “Advance person-centred care planning enables individuals to make informed decisions about their future care treatment and support. As part of this planning, DNACPR decisions can allow focus on the wishes of the individual in cases where cardiopulmonary resuscitation (CPR) may be needed. However, unless it meets the strict criteria for an advance decision to refuse treatment, a DNACPR decision itself is not legally binding. The form should be regarded as an advance clinical assessment and decision, recorded to guide immediate clinical decision-making in the event of a patient’s cardiorespiratory arrest or death. The final decision regarding whether or not attempting CPR is clinically appropriate, rests with the healthcare professionals responsible for the patient’s immediate care at that time.” Source location 2020-0084-Response-from-Dept-of-Health-and-Social-Care-Redacted
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations